Mid-upper arm circumference only protocol in Pakistan: missed opportunities for children suffering from severe acute malnutrition? A mixed-methods observational study.

OBJECTIVE: We investigated the missed treatment opportunities affecting programmes using mid-upper arm circumference (MUAC) as the sole anthropometric criterion for identification and monitoring of children suffering from severe acute malnutrition (SAM). DESIGN: Alongside MUAC, we assessed weight-for-height Z-score (WHZ) in children screened and treated according to the national MUAC only protocol in Pakistan. Besides, we collected parents' perceptions regarding the treatment received by their children through qualitative interviews. SETTING: Data were collected from October to December 2021 in Tando Allah Yar District, Sindh. SUBJECTS: All children screened in the health facilities (n 8818) and all those discharged as recovered (n 686), throughout the district, contributed to the study. All children screened in the community in the catchment areas of five selected health facilities also contributed (n 8459). Parents of forty-one children randomly selected from these same facilities participated in the interviews. RESULTS: Overall, 80·3 % of the SAM cases identified during community screening and 64·1 % of those identified in the health facilities presented a 'WHZ-only' diagnosis. These figures reached 93·9 % and 84·5 %, respectively, in children aged over 24 months. Among children treated for SAM and discharged as recovered, 25·3 % were still severely wasted according to WHZ. While parents positively appraised the treatment received by their children, they also recommended to extend eligibility to other malnourished children in their neighbourhood. CONCLUSION: In this context, using MUAC as the sole anthropometric criterion for treatment decisions (referral, admission and discharge) resulted in a large number of missed opportunities for children in need of timely and adequate care.

Arm circumference for age, arm circumference and weight-for-height z-score for the evaluation of severe acute malnutrition: a retrospective cohort study in eastern Democratic Republic of Congo.

BACKGROUND: Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnosing of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics. METHODS: We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen's kappa coefficient (κ) was calculated to assess the concordance between these indicators. RESULTS: Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 mm and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUACZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408(0.392-0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347-0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590-0.618)]. CONCLUSION: Adjusting MUAC according to age improves its effectiveness in identifying severe acute malnutrition. With low concordance, MUAC and WHZ remain complementary in our context. MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context.

Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition.

OBJECTIVE: To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN: A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS: Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS: The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.

Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan.

OBJECTIVE: We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. DESIGN: Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). SETTING: Study was conducted as part of a bigger evaluation study in South Sudan. PARTICIPANTS: International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. RESULTS: The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. CONCLUSIONS: Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.

RELATIONSHIP BETWEEN ANTHROPOMETRIC INDICES AND LEFT VENTRICULAR MASS IN CHILDREN WITH SEVERE ACUTE MALNUTRITION IN GOMBE STATE, NIGERIA.

Introduction: Severe acute malnutrition (SAM), which is diagnosed through anthropometric measurement, causes cardiac muscle wasting and this has been linked to increased mortality. Objective: This study aimed at determining the relationship between anthropometric indices and left ventricular mass (LVM) in children with SAM in Gombe State. This is to determine if anthropometric indices can be used to estimate/predict LVM in these children. Methods: One hundred and thirty-two children with SAM aged 6 to 36 months were recruited from all the five primary health care centres that offer community management of acute malnutrition in Gombe State. Their anthropometric indices (weight, height, mid-upper arm circumference (MUAC), body surface area (BSA), body mass index (BMI) and weight-for-height Z score (WHZ) were measured/derived). Their left ventricular indices were also measured using two dimensional echocardiography. Results: The mean weight, height, MUAC, BSA and BMI were 5.5+1.2kg, 69+6.1cm, 10.2+0.9cm, 0.33+0.05m2 and 11.6+1.4kg/m2, respectively. The mean LVM was 17.7+7.1g. Weight, BSA, height, BMI and MUAC had significant positive correlation with LVM [r = 0.55, r=0.53, r = 0.43, r = 0.3 and r = 0.3(p=0.001)], respectively. The determination coefficients(R2) of anthropometric indices with LVM were 0.30, 0.284 and 0.187 for weight, BSA and height, respectively. However, in multiple regression model, no anthropometric index was significantly associated with LVM. Conclusion: Some of anthropometric indices had direct linear relationship with LVM but none of them can be used to estimate/predict LVM in children with SAM in Gombe State.

Time to recovery and its predictors among children aged 6-59 months with severe acute malnutrition admitted to outpatient therapeutic program in Southwest Ethiopia: retrospective cohort study.

BACKGROUND: Outpatient therapeutic program (OTP) brings the services for the management of Severe Acute Malnutrition (SAM) closer to the community by making services available at decentralized treatment points within the primary health care setting. Despite the available interventions to tackle nutritional problems, there is scarce information on time to recovery and its predictors. Therefore, the aim of this study was to estimate time to recovery and identify its predictors among children aged 6-59 month with SAM admitted to OTP in Bench Sheko zone Southwest Ethiopia. METHODS: A retrospective cohort study was conducted on 588 children who had been managed for SAM under OTP, from September 01, 2018, to August 30, 2019, in 4 public health centers in Bench Sheko zone. A total of 1301 children's card were eligible from them 588 children's cards were selected by simple random sampling methods. Data was entered into EPI- data version 4.4.2 and exported to SPSS version 20 for analysis. Kaplan Meir estimate median time to recovery and survival curve was used to compare the time to recovery using a log-rank test among different characteristics. Cox Proportional Hazard Model was used to identify significant predictors of time to recovery. Association was summarized by using adjusted hazard ratio (AHR) and statistical significance was declared at 95% CI, and P-value < 0.05. RESULT: Recovery rate was 54.4% with the median recovery time 49 days with an Interquartile range of 21 days. The independent predictors of nutritional recovery time were: newly admitted (AHR = 1.52, 95% CI: 1.17, 2.98),had no diarrhea (AHR = 1.9, 95% CI: 1.52, 2.42), had no cough (AHR = 1.4, 95% CI: 1.13, 1.74) had no blood stool (AHR = 1.55, 95% CI: 1.14, 2.10) had no malaria (AHR = 1.75, 95% CI: 1.32, 2.32), and took deworming (AHR = 1.4, 95% CI: 1.01-1.61). CONCLUSION AND RECOMMENDATION: In the current study recovery rate and the median time of recovery is by far below the standard. Cough, diarrhea, malaria, deworming and admission status were independently associated with recovery time. Health professionals should give attention for early detection and management of co-morbidities. Minster of health should give refreshment community based management of acute malnutrition training for health workers to follow the national guideline strictly.

Time to develop severe acute malnutrition and its predictors among children living with HIV in the era of test and treat strategies at South Gondar hospitals, northwest, Ethiopia, 2021: a multicentre retrospective cohort study.

BACKGROUND: Although severe acute malnutrition is a major public issue among HIV infected children, there is no prior evidence in Ethiopia. Hence, this study aims to assess the time to develop severe acute malnutrition and its predictors among children living with human immunodeficiency virus in Ethiopia, 2012. METHODS: An institution based retrospective cohort study was conducted in South Gondar hospitals among 363 HIV infected children from February 10, 2014, to January 7, 2021. Epi-data version 3.1 was used to enter data, which was then exported to STATA version 14 for analysis. Besides, WHO (World Health Organization) Anthro Plus software was used to assess the nutritional status of the children. A standardized data extraction tool was used to collect the data. The Kaplan Meier survival curve was used to estimate the median survival time. The Cox-proportional hazard model assumption was checked via the Schoenfeld residual ph test and a stph plot. Bivariable and multivariable Cox proportional hazard models were employed at 95% confidence intervals (CI). A variable having a p-value < 0.05 was considered a statistically significant predictor of severe acute malnutrition. RESULTS: A total of 363 children living with HIV, 97 (26.72%) developed severe acute malnutrition during the follow-up period. The overall incidence rate was 5.4 (95% CI: 4.7-5.9) person per year with a total of 21, 492 months or 1791 years of observation. Moreover, the median survival time was 126 months. Treatment failure [AHR =3.4 (95% CI: 2.05-5.75)], CD4 count below threshold [AHR =2.5 (95% CI: 1.64-3.95)], and WHO stage III & IV [AHR =2.9 (95% CI: 1.74-4.73)] were all significant predictors of severe acute malnutrition. CONCLUSION: The time to develop severe acute malnutrition was found to be very low. Treatment failure, CD4 count below threshold, and WHO stage III were all significant predictors of severe acute malnutrition. Hence, emphasizing those predictor variables is essential for preventing and controlling the occurrence of severe acute malnutrition among HIV infected children.

Development and an initial validation of the Responses to Illness Severity Quantification (RISQ) score for severely malnourished children.

AIM: To develop and perform an initial validation of a score to measure the severity of illness in hospitalised children with severe acute malnutrition (SAM). METHODS: A prospective study enrolled SAM children aged 6-59 months hospitalised in Borno State, Nigeria. Candidate items associated with inpatient mortality were combined and evaluated as candidate scores. Clinical and statistical methods were used to identify a preferred score. RESULTS: The 513 children enrolled had a mean age of 15.6 months of whom 48 (9%) died. Seven of the 10 evaluated items were significantly associated with mortality. Five different candidate scores were tested. The final score, Responses to Illness Severity Quantification (RISQ), included seven items: heart rate, respiratory rate, respiratory effort, oxygen saturation, oxygen delivery, temperature and level of consciousness. The mean RISQ score on admission was 2.6 in hospital survivors and 7.3 for children dying <48 h. RISQ scores <24 h before death had an area under the receiver operating characteristic curve (AUROC) of 0.93. The RISQ score performed similarly across differing clinical conditions with AUROCs 0.77-0.98 for all conditions except oedema. CONCLUSION: The RISQ score can identify high-risk malnourished children at and during hospital admission. Clinical application may help prioritise care and potentially improve survival.

A novel screening tool to predict severe acute malnutrition through automated monitoring of weight-for-age growth curves.

Weight-for-age (WFA) growth faltering often precedes severe acute malnutrition (SAM) in children, yet it is often missed during routine growth monitoring. Automated interpretation of WFA growth within electronic health records could expedite the identification of children at risk of SAM. This study aimed to develop an automated screening tool to predict SAM risk from WFA growth, and to determine its predictive ability compared with simple changes in weight or WFA z-score. To develop the screening tool, South African child growth experts (n = 30) rated SAM risk on 100 WFA growth curves, which were then used to train an artificial neural network (ANN) to assess SAM risk from consecutive WFA z-scores. The ANN was validated in 185 children under five (63 SAM cases; 122 controls) using diagnostic accuracy methodology. The ANN's performance was compared with that of changes in weight or WFA z-score. Even though experts' SAM risk ratings of the WFA growth curves differed considerably, the ANN achieved a sensitivity of 73.0% (95% confidence interval [CI]: 60.3; 83.4), specificity of 86.1% (95% CI: 78.6; 91.7) and receiver-operating characteristic curve area of 0.795 (95% CI: 0.732; 0.859) during validation with real cases, outperforming changes in weight or WFA z-scores. The ANN, as an automated screening tool, could markedly improve the identification of children at risk of SAM using routinely collected WFA growth information.

How does baseline anthropometry affect anthropometric outcomes in children receiving treatment for severe acute malnutrition? A secondary analysis of a randomized controlled trial.

Mid-upper arm circumference (MUAC) < 11.5 cm and weight-for-height Z-score (WHZ) < -3 are used for screening for severe acute malnutrition (SAM). Underweight and concurrent wasting and stunting may better target those at the highest risk of mortality. We compared anthropometric outcomes in children enrolled in a trial of antibiotics for SAM based on categories of baseline anthropometry, including indicators for programme admission (WHZ < -3, MUAC < 11.5) and alternative indicators (weight-for-age Z-score [WAZ] < -3, concurrent wasting and stunting [WHZ < -3 and height-for-age Z-score < -3]). Participants were followed weekly until nutritional recovery and at 8 weeks. We evaluated changes in weight gain (g/kg/day), MUAC, and WHZ in children admitted by admissions criteria (MUAC only, WHZ only, or MUAC and WHZ) and by underweight or concurrent wasting and stunting. Of 301 admitted children, 100 (33%) were admitted based on MUAC only, 41 (14%) WHZ only, and 160 (53%) both MUAC and WHZ, 210 (68%) were underweight and 67 (22%) were concurrently wasted/stunted. Low MUAC and low WHZ children had the lowest probability of nutritional recovery (17% vs. 50% for MUAC-only and 34% for WHZ-only). There was no difference in weight gain velocity or WHZ by admissions criteria (WHZ and/or MUAC). Underweight and concurrently wasted/stunted children had lower MUAC and WHZ at 8 weeks compared with those who were not underweight or concurrently wasted and stunted. Children with both low MUAC and low WHZ had the worst outcomes. Relying on MUAC alone may miss children who have poor outcomes. Other indicators, such as WAZ, may be useful for identifying vulnerable children.

Diagnostic measures for severe acute malnutrition in Indian infants under 6 months of age: a secondary data analysis.

BACKGROUND: Weight for length z-score (WLZ) < - 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is < 45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. METHODS: The data was from an individually randomized trial conducted in slums of Delhi, India in which infants' weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for WAZ < -3, WLZ < -3, and LAZ < -3 for deaths between 6 weeks and 6 months of age. The receiver operating characteristics curve was calculated for each of the above anthropometric indicators. RESULTS: For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9-95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6% for WAZ < -3, 39.1% for LAZ < -3, and 25.0% for WLZ < -3. WAZ < -3 had higher area under curve (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ < -3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9, 95% CI 38.8, 71.0%) of mortality was highest for WAZ < -3. CONCLUSIONS: We found WAZ < -3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ < -3 and LAZ < -3 and propose that it should be considered to diagnose SAM in this age group.

A feasibility study to assess non-clinical community health workers' capacity to use simplified protocols and tools to treat severe acute malnutrition in Niger state Nigeria.

BACKGROUND: Severe acute malnutrition (SAM) is a major determinant of childhood mortality and morbidity. Although integrated community case management (iCCM) of childhood illnesses is a strategy for increasing access to life-saving treatment, malnutrition is not properly addressed in the guidelines. This study aimed to determine whether non-clinical Community Health Workers (called Community-Oriented Resource Persons, CORPs) implementing iCCM could use simplified tools to treat uncomplicated SAM. METHODS: The study used a sequential multi-method design and was conducted between July 2017 and May 2018. Sixty CORPs already providing iCCM services were trained and deployed in their communities with the target of enrolling 290 SAM cases. Competency of CORPs to treat and the treatment outcomes of enrolled children were documented. SAM cases with MUAC of 9 cm to < 11.5 cm without medical complications were treated for up to 12 weeks. Full recovery was at MUAC≥12.5 cm for two consecutive weeks. Supervision and quantitative data capturing were done weekly while qualitative data were collected after the intervention. RESULTS: CORPs scored 93.1% on first assessment and increment of 0.11 (95% CI, 0.05-0.18) points per additional supervision conducted. The cure rate from SAM to full recovery, excluding referrals from the denominator in line with the standard for reporting SAM recovery rates, was 73.5% and the median length of treatment was 7 weeks. SAM cases enrolled at 9 cm to < 10.25 cm MUAC had 31% less likelihood of recovery compared to those enrolled at 10.25 cm to < 11.5 cm. CORPs were not burdened by the integration of SAM into iCCM and felt motivated by children's recovery. Operational challenges like bad terrains for supervision, supply chain management and referrals were reported by supervisors, while Government funding was identified as key for sustainability. CONCLUSION: The study demonstrated that with training and supportive supervision, CORPs in Nigeria can treat SAM among under-fives, and refer complicated cases using simplified protocols as part of an iCCM programme. This approach seemed acceptable to all stakeholders, however, the effect of the extra workload of integrating SAM into iCCM on the quality of care provided by the CORPs should be assessed further.

Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan.

BACKGROUND: Weight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children. METHODS: The data of this study is from World Vision South Sudan's emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain. RESULTS: As acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children. CONCLUSIONS: The relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.

Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study.

BACKGROUND: Despite consistent efforts to enhance child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6 to 59 months in the two districts of Nepal. METHODS: We used data from a cross-sectional study conducted among 6 to 59 months children admitted to the Outpatient Therapeutic Care Centers (OTCC). The nutritional status of children was assessed using mid-upper arm circumference (MUAC) measurement. To determine which variables predict the occurrence of SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value < 0.05 was considered as significant. RESULTS: Out of 398 children, 5.8% were severely malnourished and the higher percentage of female children were malnourished. Multivariate analysis showed that severe acute malnutrition was significantly associated with family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23-12.71). Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88-10.53) were four times more likely to be severely malnourished. Higher odds of SAM were found among younger age-group (AOR: 12.10; 95% CI: 2.06-71.09) children (0-12 vs. 24-59 months). CONCLUSIONS: The findings of this study indicated that household size, household food access, and the child's age were the major predictors of severe acute malnutrition. Engaging poor families in kitchen gardening to ensure household food access and nutritious diet to the children, along with health education and promotion to the mothers of young children are therefore recommended to reduce child undernutrition.

Combined protocol for severe and moderate acute malnutrition in emergencies: Stakeholders perspectives in four countries.

Each year, acute malnutrition affects an estimated 52 million children under 5 years of age. Current global treatment protocols divide treatment of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) despite malnutrition being a spectrum disease. A proposed Combined Protocol provides for (a) treatment of MAM and SAM at the same location; (b) diagnosis using middle-upper-arm circumference (MUAC) and oedema only; (c) treatment using a single product, ready-to-use-therapeutic food (RUTF), and (d) a simplified dosage schedule for RUTF. This study examines stakeholders' knowledge of and opinions on the Combined Protocol in Niger, Nigeria, Somalia, and South Sudan. Data collection included a document review followed by in-depth interviews with 50 respondents from government, implementing partners, and multilateral agencies, plus 11 global and regional stakeholders. Data were analysed iteratively using thematic content analysis. We find that acute malnutrition protocols in these countries have not been substantially modified to include components of the Combined Protocol, although aspects were accepted for use in emergencies. Respondents generally agreed that MAM and SAM treatment should be provided in the same location, however they said MUAC and oedema-only diagnosis, although more field-ready than other diagnostic measures, did not necessarily catch all malnourished children and may not be appropriate for "tall and slim" morphologies. Similarly, using only RUTF presented inherent logistical advantages, but respondents worried about pipeline issues. Respondents did not express strong opinions about simplified dosage schedules. Stakeholders interviewed indicated more evidence is needed on the operational implications and effectiveness of the Combined Protocol in different contexts.

A descriptive study of double burden of malnutrition in mothers of children with severe acute malnutrition admitted in Children Hospital and Institute of Child Health, Multan.

OBJECTIVE: To assess the nutritional status of mothers of severely malnourished children, and to evaluate the factors associated with inadequate caloric intake of children with severe acute malnutrition versus sufficient caloric intake by mothers. METHODS: The cross-sectional descriptive study was conducted from January to June 2016 at Children Hospital and Institute of Child Health, Multan, Pakistan, and comprised mothers of severely malnourished children admitted for treatment. Data was collected using a questionnaire administered through interviews. Elements noted included body mass index, 24-hour recall, dietary restriction during pregnancy, lactation and complimentary feeding patterns of the children. The mothers were also examined for clinical signs of iron deficiency anaemia. RESULTS: Of the 100 women, 20(20%) were malnourished, 42(42%) were of normal weight, and 38(38%) were either overweight, pre-obese or obese. The caloric intake of 26(26%) mothers was less than 1500 kcal per day, while 42(42%) were taking between 2000-2500 kcal per day and 32(32%) were taking >2500 kcal daily. Also, 67(67%) women were suffering from anaemia and 80(80%) women had some myths related with dietary restrictions during pregnancy, lactation and complimentary feeding of children. Overall, 23(23%) women breastfed their babies.

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial.

BACKGROUND: Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase. METHODS AND FINDINGS: In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite. CONCLUSIONS: Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM. TRIAL REGISTRATION: ClinicalTrials.gov NCT02246296.

Community engagement to manage acute malnutrition: implementation research in Kupang district, Indonesia.

OBJECTIVE: To improve the low coverage and performance of a programme on community-based management of acute malnutrition, implemented between October 2015 and April 2018 in Kupang district in rural Indonesia. METHODS: To investigate why the coverage and performance were low in the first year of the programme, we conducted a semiquantitative evaluation between August and September 2016. We used the results from the evaluation to inform programme improvement, by developing and modifying community mobilization strategies. We employed a multipronged approach to improve community awareness on acute malnutrition and on community-based services for such condition. This approach involved workshops, focus discussion groups in the community and sensitization events at health posts that had issues with community engagement. Community health workers increased their efforts in active case finding by visiting households with children who had missed the community health post sessions. We measured the performance using three Sphere minimum standard performance indicators: proportion of children recovering (> 75%); defaulting (< 15%); and dying (<10%). RESULTS: The community mobilization efforts increased the screening rate from 17% (564/3278) in October 2015 to 66% (6793/10 251) in March 2018. In 2017, the programme met the three performance indicators: 79% (256/326) of children recovered; 10% (34/326) defaulted; and less than 1% (2/326) died. CONCLUSION: In Indonesia, community mobilization is central for addressing severe acute malnutrition in children younger than five years. This strategy includes securing political leadership and effective messaging alongside locally tailored strategies and continuous ground-level support.

Active and adaptive case finding to estimate therapeutic program coverage for severe acute malnutrition: a capture-recapture study.

BACKGROUND: Coverage is an important indicator to assess both the performance and effectiveness of public health programs. Recommended methods for coverage estimation for the treatment of severe acute malnutrition (SAM) can involve active and adaptive case finding (AACF), an informant-driven sampling procedure, for the identification of cases. However, as this procedure can yield a non-representative sample, exhaustive or near exhaustive case identification is needed for valid coverage estimation with AACF. Important uncertainty remains as to whether an adequate level of exhaustivity for valid coverage estimation can be ensured by AACF. METHODS: We assessed the sensitivity of AACF and a census method using a capture-recapture design in northwestern Nigeria. Program coverage was estimated for each case finding procedure. RESULTS: The sensitivity of AACF was 69.5% (95% CI: 59.8, 79.2) and 91.9% (95% CI: 85.1, 98.8) with census case finding. Program coverage was estimated to be 40.3% (95% CI 28.6, 52.0) using AACF, compared to 34.9% (95% CI 24.7, 45.2) using the census. Depending on the distribution of coverage among missed cases, AACF sensitivity of at least ≥70% was generally required for coverage estimation to remain within ±10% of the census estimate. CONCLUSION: Given the impact incomplete case finding and low sensitivity can have on coverage estimation in potentially non-representative samples, adequate attention and resources should be committed to ensure exhaustive or near exhaustive case finding. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT03140904. Registered on May 3, 2017.

Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson's paradox.

BACKGROUND: According to WHO childhood severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO2006 standards, the mid-upper-arm circumference (MUAC) is < 115 mm, there is nutritional oedema or any combination of these parameters. Recently there has been a move to eliminate WHZ as a diagnostic criterion on the assertion that children meeting the WHZ criterion are healthy, that MUAC is universally a superior prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction; these assertions have lead to a controversy concerning the role of WHZ in the diagnosis of SAM. METHODS: We examined the mortality experience of 76,887 6-60 month old severely malnourished children admitted for treatment to in-patient, out-patient or supplementary feeding facilities in 18 African countries, of whom 3588 died. They were divided into 7 different diagnostic categories for analysis of mortality rates by comparison of case fatality rates, relative risk of death and meta-analysis of the difference between children admitted using MUAC and WHZ criteria. RESULTS: The mortality rate was higher in those children fulfilling the WHO2006 WHZ criterion than the MUAC criterion. This was the case for younger as well as older children and in all regions except for marasmic children in East Africa. Those fulfilling both criteria had a higher mortality. Nutritional oedema increased the risk of death. Having oedema and a low WHZ dramatically increased the mortality rate whereas addition of the MUAC criterion to either oedema-alone or oedema plus a low WHZ did not further increase the mortality rate. The data were subject to extreme confounding giving Simpson's paradox, which reversed the apparent mortality rates when children fulfilling both WHZ and MUAC criteria were included in the estimation of the risk of death of those fulfilling either the WHZ or MUAC criteria alone. CONCLUSIONS: Children with a low WHZ, but a MUAC above the SAM cut-off point are at high risk of death. Simpson's paradox due to confounding from oedema and mathematical coupling may make previous statistical analyses which failed to distinguish the diagnostic groups an unreliable guide to policy. WHZ needs to be retained as an independent criterion for diagnosis of SAM and methods found to identify those children with a low WHZ, but not a low MUAC, in the community.